group health cooperative 2015 medicare advantage plan 3 ... ghc medicare...group health employer...

of 13

MEDICAREADVANTAGE

HMO

Group Health Medicare Advantage Employer Group (HMO)

Summary of BenefitsGroup Health Cooperative 2015 Medicare Advantage Plan 3— Group Retiree Prescription Drug Benefits

BENEFITS EFFECTIVE: January 1, 2015 – December 31, 2015

H5050

14-MED-1453-02

Questions?1-888-901-4600TTY WA Relay: 1-800-833-6388 or 711

Monday–Friday, 8 a.m.– 8 p.m.Extended hours October 1– February 14 Daily 8 a.m.– 8 p.m.

medicare.ghc.org

of 13

GROUP HEALTH EMPLOYER GROUP WITH PART D(a Medicare Advantage Health Maintenance Organization (HMO) offered by GROUP HEALTH COOPERATIVE with a Medicare contract)

Summary of BenefitsJanuary 1, 2015–December 31, 2015

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”

You have choices about how to get your Medicare benefits

One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government.

Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Group Health Employer Group with Part D (HMO)).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Group Health Employer Group with Part D (HMO) covers and what you pay.

If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Sections in this booklet • Things to Know About Group Health Employer Group with Part D (HMO)• Monthly Premium, Deductible, and Limits on How Much You Pay for

Covered Services• Covered Medical and Hospital Benefits• Prescription Drug Benefits

This document is available in other formats such as Braille and large print.

This document may be available in a non-English language. For additional information:

• Current members should call (206) 901-4600 or (888) 901-4600. (TTY/TDD (800) 833-6388 or 711)

• Prospective members should call (800) 446-8882. (TTY/TDD (800) 833-6388 or 711)

of 13

Things to Know About Group Health Employer Group with Part D (HMO)

Hours of operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time.From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time.

Group Health Cooperative Employer Group with Part D (HMO) phone numbers and Website

• If you are a member of the plan, call (206) 901-4600 or (888) 901-4600. (TTY/TDD (800) 833-6388 or 711)

• If you are not a member of this plan, call (800) 446-8882. (TTY/TDD (800) 833-6388 or 711)

• Our website: medicare.ghc.org

Who can join? To join Group Health Employer Group with Part D (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.Our service area includes the following counties in Washington: Grays Harbor*, Island, King, Kitsap, Lewis, Mason*, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, and Whatcom.* denotes partial county

Which doctors, hospitals, and pharmacies can I use?

Group Health Employer Group with Part D (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.You can see our plan’s provider and pharmacy directory at our website (medicare.ghc.org).Or, call us and we will send you a copy of the provider and pharmacy directory.

What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers —and more.• Our plan members get all of the benefits covered by Original Medicare.

For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less.

• Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.• You can see the complete plan formulary (list of Part D prescription drugs)

and any restrictions on our website, medicare.ghc.org. • Or, call us and we will send you a copy of the formulary.

of 13

Summary of Benefits for Contract H5050, Plan 802-3

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? Please contact your retiree benefit center for details

about your monthly premiums (if applicable). In addition, you must keep paying your Medicare Part B premium.

How much is the deductible? This plan does not have a deductible.

Is there any limit on how much I will pay for my covered services?

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.

In this plan, you will pay nothing for Medicare-covered services from in-network providers.

Your yearly limit(s) in this plan:

• $2,500 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Is there a limit on how much the plan will pay? No. There are no limits on how much our plan will pay.

Group Health Cooperative is an HMO plan with a Medicare contract. Enrollment in Group Health HMO depends on contract renewal.

of 13

Covered Medical and Hospital Benefits NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION.

SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR.

Benefit

OUTPATIENT CARE AND SERVICES

Acupuncture and Other Alternative Therapies Acupuncture: $10 copay, up to 8 visits

Naturopath: $10 copay, up to 3 visits

Chiropractic: $10 copay, up to 10 visits

Ambulance1 $0–150 copay, depending on the service

Hospital to hospital ambulance transfers initiated by Group Health: You pay nothing

Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $10 copay

Dental Services1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing

Diabetes Supplies and Services1,2 Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing

Diagnostic Tests, Lab and Radiology Services, and X-Rays1,2

Diagnostic radiology services (such as MRIs, CT scans): You pay nothing

Diagnostic tests and procedures: You pay nothing

Lab services: You pay nothing

Outpatient x-rays: You pay nothing

Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing

Doctor’s Office Visits1,2 Primary care physician visit: $10 copay

Specialist visit: $10 copay

Durable Medical Equipment (wheelchairs, oxygen, etc.)1

You pay nothing


Benefit

of 13

Emergency Care $65 copay

If you are admitted to the hospital within 1 day, you do not have to pay your share of the cost for emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs.

Foot Care (podiatry services)1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $10 copay

Hearing Services Exam to diagnose and treat hearing and balance issues: $10 copay

Routine hearing exam: Not covered

Hearing aid fitting/evaluation (for up to 1 every year): $10 copay

Hearing aid: You pay nothing. Our plan pays up to $250 every 24 months for hearing aids

Home Health Care1,2 You pay nothing

Mental Health Care1,2 Inpatient visit:

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

You pay nothing per admittance for Medicare-covered hospital stays

Outpatient group therapy visit: $10 copay

Outpatient individual therapy visit: $10 copay

Medicare-covered partial hsopitalization program services: You pay nothing

Benefit

of 13

Outpatient Rehabilitation1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $10 copay

Occupational therapy visit: $10 copay

Physical therapy and speech and language therapy visit: $10 copay

Outpatient Substance Abuse1,2 Group therapy visit: You pay nothing

Individual therapy visit: You pay nothing

Outpatient Surgery1,2 Ambulatory surgical center: $10 copay

Outpatient hospital: $10 copay

Over-the-Counter Items Not Covered

Prosthetic Devices (braces, artificial limbs, etc.)1 Prosthetic devices: You pay nothing

Related medical supplies: You pay nothing

Renal Dialysis2 You pay nothing

Medicare-covered kidney disease education services: You pay nothing

Transportation Not covered

Urgent Care $10 copay

Vision Services2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $10 copay

Eyeglasses or contact lenses after cataract surgery: You pay nothing

Routine eye exam (for up to 1 every year): $10 copay

Contact lenses: You pay nothing

Eyeglasses (frames and lenses): You pay nothing. Our plan pays up to $150 every 12 months for contact lenses and eyeglasses (frames and lenses).


Benefit

of 13

Preventive Care1,2 You pay nothing

Our plan covers many preventive services, including:

• Abdominal aortic aneurysm screening• Alcohol misuse counseling• Bone mass measurement• Breast cancer screening (mammogram)• Cardiovascular disease (behavioral therapy)• Cardiovascular screenings• Cervical and vaginal cancer screening• Colonoscopy• Colorectal cancer screenings• Depression screening• Diabetes screenings• Fecal occult blood test• Flexible sigmoidoscopy• HIV screening• Medical nutrition therapy services• Obesity screening and counseling• Prostate cancer screenings (PSA)• Sexually transmitted infections screening

and counseling• Tobacco use cessation counseling (counseling for

people with no sign of tobacco-related disease)• Vaccines, including Flu shots, Hepatitis B shots,

Pneumococcal shots• “Welcome to Medicare” preventive visit (one-time)• Yearly “Wellness” visit

Any additional preventive services approved by Medicare during the contract year will be covered.

Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

INPATIENT CARE

Inpatient Hospital Care1,2 Our plan covers an unlimited number of days for an inpatient hospital stay.

You pay nothing per admittance

Inpatient Mental Health Care For inpatient mental health care, see the “Mental Health Care” section of this booklet.

Benefit

of 13

Skilled Nursing Facility (SNF)1,2 Our plan covers up to 100 days in a SNF.

You pay nothing

PRESCRIPTION DRUG BENEFITS

How much do I pay? For Part B drugs such as chemotherapy drugs1: You pay nothing

Other Part B drugs1: You pay nothing

Home infusion drugs, supplies, and services: You pay nothing

Outpatient Prescription Drugs

You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

Standard Retail Cost-Sharing

Tier One-month supply Two-month supply Three-month supply

Tier 1 (Preferred Generic) $10 copay $20 copay $30 copay

Tier 2 (Non-Preferred Generic) $20 copay $40 copay $60 copay

Tier 3 (Preferred Brand) $40 copay $80 copay $120 copay

Tier 4 (Non-Preferred Brand) $90 copay $180 copay $270 copay

Tier 5 (Specialty Tier) $150 copay Not Offered Not Offered

Standard Mail Order Cost-Sharing

Tier One-month supply Two-month supply Three-month supply

Tier 1 (Preferred Generic) $10 copay $20 copay $20 copay

Tier 2 (Non-Preferred Generic) $20 copay $40 copay $40 copay

Tier 3 (Preferred Brand) $40 copay $80 copay $80 copay

Tier 4 (Non-Preferred Brand) $90 copay $180 copay $180 copay

Tier 5 (Specialty Tier) $150 copay Not Offered Not Offered


Benefit

of 13

Additional Information

Additional counseling to stop smoking and tobacco use

Individual telephone-based tobacco cessation program includes up to 5 counseling calls from Quit for Life Program staff, dedicated support line, guides, and an individual plan. You can enroll multiple times during the year.

Fitness Program You pay nothing for the SilverSneakers Fitness Program at any of the contracted fitness facilities for Medicare Advantage members.

Massage Therapy (from a licensed massage therapist)¹

$10 copay for 10 medically necessary visits per year—prior authorization required.

Nursing Hotline You pay nothing for Group Health’s consulting nurse line.

of 13

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-888-901-4600. Someone who speaks English/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-888-901-4600. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致电 1-888-901-4600。我们的中文工作人员很乐意帮助

您。这是一项免费服务。

Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電1-888-901-4600。我們講中文的人員將樂意為您提供幫助。

這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-888-901-4600. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-888-901-4600. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-888-901-4600 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie 1-888-901-4600. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화1-888-901-4600 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.


of 13

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-888-901-4600. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:

. لدينا الأدوية جدول أو بالصحة تتعلق أسئلة أي عن للإجابة المجانية الفوري رجمالمت خدمات نقدم إننا ما شخص سيقوم. .4600-901-888-1 على بنا الاتصال سوى عليك ليس فوري، مترجم على للحصول

العربية يتحدث مجانية خدمة ھذه. بمساعدتك .

Hindi: हमारे �वा��य या दवा की योजना के बारे म� आपके िकसी भी ��न के जवाब देने के िलए हमारे पास म�ुत दभुािषया सेवाएँ �पल�� ह�. एक दभुािषया �ा�त करने के िलए, बस हम� 1-888-901-4600

पर फोन कर�. कोई �यिक्त जो �ह�द� बोलता है आपकी मदद कर सकता है. यह एक म�ुत सेवा है. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-901-4600. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-888-901-4600. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-901-4600. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-888-901-4600. Ta usługa jest bezpłatna. Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、 1-888-901-4600 にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-888-901-4600. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:

. لدينا الأدوية جدول أو بالصحة تتعلق أسئلة أي عن للإجابة المجانية الفوري رجمالمت خدمات نقدم إننا ما شخص سيقوم. .4600-901-888-1 على بنا الاتصال سوى عليك ليس فوري، مترجم على للحصول

العربية يتحدث مجانية خدمة ھذه. بمساعدتك .

Hindi: हमारे �वा��य या दवा की योजना के बारे म� आपके िकसी भी ��न के जवाब देने के िलए हमारे पास म�ुत दभुािषया सेवाएँ �पल�� ह�. एक दभुािषया �ा�त करने के िलए, बस हम� 1-888-901-4600

पर फोन कर�. कोई �यिक्त जो �ह�द� बोलता है आपकी मदद कर सकता है. यह एक म�ुत सेवा है. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-888-901-4600. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-888-901-4600. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-888-901-4600. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-888-901-4600. Ta usługa jest bezpłatna. Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービスがありますございます。通訳をご用命になるには、 1-888-901-4600 にお電話ください。日本語を話す人者が支援いたします。これは無料のサービスです。

Customer Service Toll-free 1-888-901-4600TTY WA Relay: Toll-free 1-800-833-6388 or 711

Monday–Friday, 8 a.m.–8 p.m.

Extended hours October 1–February 14 Daily 8 a.m.–8 p.m.

medicare.ghc.org

group health cooperative 2015 medicare advantage plan 3 ... ghc medicare...group health employer...

Documents